Solid Waste Origin Disposal Form – Fill Out and Use This PDF

NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION-DIVISION OF SOLID AND HAZARDOUS WASTE

SOLID WASTE ORIGIN AND DISPOSAL FORM

A. Transporter Section (To be completed by the Transporter PRIOr to transport to the disposal site)

1.

Name of Registered Transporter: ______________________________________ Phone No. ____________________ 2. NJDEP Registration No.:

__________________

3.

Type of Transporter Registration: (Check One)

A-901 Licensed

Registered self-generator

Registration Exempt 4. Waste Self- Generated: (Check One)

YES

NO

5.

Name of LESSOR if the solid waste vehicle is leased: ________________________________________________________

6.

Decal No.

Type

License Plate No.

Capacity

Leased – Yes or No

7. A. Waste Types (Please circle)

ID 10

ID 13

ID 13C

ID 23

______________

Cab or Single Unit

________________

___________

________________

ID 25

ID 27

ID 27A

ID 27I

Other:__________________

______________

Container

______N/A_______

___________

________________

B. Source Separated Recyclables: (Please circle)

Paper

/

Corrugated

/

Glass /

Metal / Plastics

______________

Trailer

________________

___________

________________

Concrete

/ Asphalt

/

Wood

/

Yard Material

8. Transporter to complete waste origin information.

Other: __________________________________

Municipality (ies)

County(ies)

State

% of Total Load

_______________________

____________________

_______

____________________

* Sending Facility: (If solid waste is transported

from a solid waste intermodal, transfer, or material

_______________________

____________________

_______

____________________

recovery facility, list the facility name in the

Municipality column, ID # in the County column

_______________________

____________________

_______

____________________

and the State in which the sending facility is

located in the State column.)

___________________

_________________

______

_________________

9. Date Waste Collected: ________________

10.Transporter’s Certification: I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.

_____________________________	_________________________	______________
PRINT DRIVER’S NAME	SIGNATURE	DATE
B. Disposal Destinations

11.Final Disposal Facility Name & State (Transporter Completes 11 & 12): ________________________________________________________________________________

12.Non Hazardous Manifest # or Bill of Lading # or Pull Ticket #: ______________________________

13.In State weigh location (Weigh master completes 13 through 16): ____________________________________________________________________________________

14. GROSS WT.:___________________ NET WT. (IN STATE DISPOSAL ONLY):____________________

15. SCALE TICKET No. (IN STATE DISPOSAL ONLY):_________________

16.Weigh master’s Certification: I CERTIFY THAT THIS FORM HAS BEEN COMPLETED BY THE REGISTERED TRANSPORTER IDENTIFIED ABOVE, AND THAT THE GROSS WEIGHT FIGURE IS TRUE AND ACCURATE FOR LOADS GOING OUT OF STATE.

SIGNATURE:____________________________________DATE:___________________

C.In State Disposal Facility Section (To be completed by facility operator for loads disposed of in State only)

17.New Jersey Receiving Facility Operator Certification: I CERTIFY THAT THIS FORM HAS BEEN COMPLETED BY THE REGISTERED TRANSPORTER IDENTIFIED ABOVE, AND THAT THE WASTE AS IDENTIFIED BY THE TRANSPORTER IS PERMITTED TO BE DISPOSED OF AT THIS FACILITY

Receiving Facility Permit or ID#.: ______________________DATE___________ TIME___________OPERATOR’S STAMP OR SIGNATURE_______________________

Instructions for completing NJDEP Solid Waste Origin And Disposal Form

1.Name of Registered Transporter and Phone Number: The transporter must use the registered trade name of the transporter as identified on the NJDEP Solid Waste Transporter Registration along with the appropriate telephone number (including area code) of the company. Nicknames, aliases and abbreviations are not acceptable.

2.NJDEP registration No.: The correct NJDEP Solid Waste Transporter Registration Number must be filled out. This number appears on the registration certificate which must be carried with the vehicle.

3.Type of Transporter Registration: The appropriate box must be checked depending on whether the transporter is licensed, is a self generator exempted from licensing requirements, or the vehicle is not subject to NJDEP registration requirements.

4.Waste Self Generated: The appropriate box must be checked to disclose whether the waste was self generated by the entity performing the transportation.

5.Name of LESSOR if the solid waste vehicle is leased: The name of the lessor as indicated on the lease must be filled in if the vehicle is leased. The lease must be carried in the registered vehicle.

6.Decal No., Type, License Plate No., Capacity, and Leased: The decal number must be filled in for the appropriate type of registered equipment (i.e. container, trailer, cab, etc.). The License plate must also be filled in for the appropriate equipment along with the capacity (i.e. 30 cubic yard container). Yes or No must be filled in next to the appropriate type of equipment to indicate if it is leased.

7.Waste Types and Source Separated Recyclables: The transporter must indicate the type(s) of waste being transported by circling the appropriate waste types. An example of “other” would be non hazardous bulk liquid (type 72) for example. If a load consists of source separated recyclables the transporter must circle the appropriate material. If the load consists of more than one co-mingled type of recyclable, “co-mingled” must be indicated under the “Other” section along with the approximate percentages (i.e. co-mingled paper 25%, metal 50%, plastics 25%)

8.Municipality, County State, % of Load: The transporter must identify the waste origin by municipality, county, and state along with the respective percentage of each waste origin. In the event waste is transported from one solid waste facility to another (for example from a transfer station to a landfill for disposal) the transporter must indicate the sending facility’s name in the municipality column, the facility permit # in the County column, and the State in which the sending facility is located in the State column, in addition to the waste origin(s). The percentage of waste sent from a single solid waste facility such as a transfer station should be recorded as 100%.

9.Date Waste Collected: The transporter must fill in the actual date the solid waste was collected.

10.Transporter’s Certification: The driver representing the transporter must print and sign his/her name and date to certify the information in the Transporter Section was completed accurately.

11.Final Disposal Facility Name & State: The transporter must fill in the final disposal facility name and State in which the facility is located.

12.Non Hazardous Manifest # or Bill of Lading # or Pull Ticket #: The transporter must identify the appropriate manifest or bill of lading number for loads being transported for out of State disposal. The pull ticket number must be recorded for all loads where such a document is generated.

13.In State weigh location: The weigh master must complete the location of the weighing facility. For most instances of in State disposal this is the same location as the disposal facility, however in cases involving loads being transported out of State, the weigh location may be designated to be a location other than a disposal facility.

14.Gross Wt. And Net Wt.: The weigh master must complete the gross weight for all vehicles transporting waste and recyclables into solid waste facilities within this State. The gross weight must also be completed for all loads destined for out of State waste disposal facilities. The net weight must be recorded for all loads being disposed of in this State.

15.Scale ticket #. The weigh master must record the appropriate scale ticket # generated for loads received for disposal within this State.

16.Weigh master’s Certification: The weigh master must certify the information he or she recorded is accurate.

17.New Jersey Receiving Facility Operator Certification: The person responsible for recording information for loads received at New Jersey solid waste facilities must fill in the facility number the date and time and stamp or sign the the form to certify the form was completed by the transporter and that the waste identified by the transporter is permitted to be accepted at the facility for disposal.

Failure to carefully follow these instructions in accurately completing the Solid Waste Origin and Disposal Form can lead to enforcement action including penalties.

Waste Type ID 10 = municipal solid waste

Waste Type ID 13 = bulky solid waste

Waste Type ID 13C = construction & demolition debris

Waste Type ID 23 = vegetative waste

Waste Type ID 25 = animal and food processing waste

Waste Type ID 27 = dry industrial waste

Waste Type ID 27A = asbestos containing waste

Waste Type ID 27I = incinerator ash